Final Meaningful Use Stage 2 Rule Commentary--"Now Is the Time"

Joe Wivoda, Chief Information Officer

The final rule for Stage 2 of Meaningful Use came out August 23rd--earlier than expected and with few actual surprises. CMS took the public comments seriously and modified the proposed rule in many areas based on those comments. The final rule is released with commentary and is a full 672 pages long, and this overview is based on a quick review. More information will be available as we dig into the rule further.

Don't forget, this rule does not go into effect until 2014 at the earliest. If you attest to Meaningful Use Stage 1 you get two years to reach Stage 2, unless you attested in 2011, in which you get three years.

There is no reason to panic, you have time to understand the new rule, but there are some themes that are important to be aware of now.

Utilize Your EHR

The menu requirements for Stage 1 have, for the most part, been incorporated into core requirements in Stage 2. Many of the core requirements have higher thresholds under Stage 2. This means that you will need to utilize your EHR more. For example, in Stage 1 the CPOE requirement was that 30% of patients have at least one medication order. One could argue that if you met that requirement exactly, and no more, you would be operating in a less safe manner, since you now have multiple processes for the same tasks. The new rule for CPOE is that 60% of medication, 30% of lab, and 30% of radiology ORDERS need to be in CPOE.

Now is the time to understand the new core requirements and begin planning and redesigning workflows to meet them.

Information Exchange

Electronically transmitting information for transitions of care for 10% of care transitions is a new requirement for Stage 2. The work that is being done on HIEs today will create the infrastructure for these transmissions, but more work will need to be done. Since so many hospital discharges are to long term care (LTC) facilities, hospitals will need to work with them to participate in the HIE. LTC does not receive any incentives for Meaningful Use, and many LTC EHRs are not prepared to exchange information today (though some are).

Now is the time to consider your referral patterns and engage those providers to begin planning for information exchange.

Patient Engagement

Under Stage 1 providers only needed to provide electronic information to patients when they asked for it, and then providers were only required to provide it 50% of the time. Stage 2 will require hospitals and eligible professionals to not only provide the information, but it also requires that 5% of patients access their information through a portal. There is also a requirement that 5% of patients are communicated with using secure messaging. There are exclusions for areas that have limited Internet connectivity, but almost all providers will need to meet these requirements.

Now is the time to talk with your vendor about their portal offerings, or if they can interface with a Personal Health Record (PHR), and begin planning how you will engage patients to actively view their information online.

Clinical Quality Measures

The requirements for Clinical Quality Measure reporting in Stage 1 were fairly easy, although the measures did not necessarily apply well to rural facilities. The new rule provides many more options for reporting and electronic submission will be required. More information will be available about the quality measures that you can choose from.

Now is the time to speak with your vendor to make sure that the reports you think are most appropriate are incorporated into the Stage 2-certified version of your EHR.

Some Changes to Stage 1

There are some changes to Stage 1 requirements that go into effect in 2013 and 2014. Many are additional exclusions. For example, if you can demonstrate that collecting some vitals are not part of the scope of your practice (e.g. Chiropractor), then you do not need to meet the objective of collecting vitals. The requirement of exchanging clinical information will be removed in 2013, but since the Stage 2 exchange requirements are so important, you cannot put off work on the exchange requirements.

Now is the time, if you have questions about those exclusions, to understand the changes to Stage 1.

Conclusion

The new Stage 2 rules for Meaningful Use have only been out for a few hours, and for the most part do not go into effect until 2014 at the earliest. This provides time to fully understand the rules and begin discussions with your vendors, referral partners, patients, HIE, and other stakeholders to properly prepare to meet the rules. The purpose of these new rules is to encourage health care providers to utilize electronic systems to be more safe and efficient, and to improve quality. Information exchange between providers of care and providing relevant clinical information directly to patients electronically are important ways to achieve these goals.

More Information

CMS final rule * CMS final rule (42 CFR Parts 412, 413, and 495) * Fact sheet on CMS's final rule

ONC standards and certification criteria final rule * ONC final rule (45 CFR Part 170) * Fact sheet on ONC's standards and certification criteria final rule - forthcoming

More information on the Stage 2 rule * HHS news release * CMS EHR Incentive Programs website

A Lot to Learn from the Last Frontier

Joe Wivoda, Chief Information Officer

Rural health care faces many challenges, such as workforce attraction and retention, geographic constraints, and the high cost of HIT.  These problems are magnified in Alaska.  With a population of less than 750,000 (47th in the US) and an average density of 1.2 people per square mile, it becomes clear why The Last Frontier presents so many challenges to health care (and I didn't even mention the winter weather).  As part of our Technical Assistance to Rural Health HIT Network Development grantees I was privileged to spend a few days in Alaska getting more acquainted with them and how they overcome some of the challenges to providing healthcare in this beautiful state.

With so much land area and low population density it is difficult to provide traditional access to health care.  Some clinics are hundreds of miles from a hospital, and with Alaska's unpredictable weather flying can be difficult.  The Alaska Native Tribal Health Consortium (ANTHC) has created a vast telemedicine network to support rural clinics.  During my visit with Richard Hall at ANTHC, I learned that they have been doing amazing work to bring primary care services to remote areas using HIT, while coordinating the efforts of several organizations to make it happen.

One of the organizations that ANTHC partners with is the Tanana Chiefs Conference.  I was able to spend the day with Jim Williams at Tanana Chiefs and visited the clinic in Nenana.  At the clinic I talked with a Community Health Aid/Practitioner (CHAP) that provides care to several patients each day.  The CHAP program was designed to overcome workforce shortages that exist in small villages across Alaska and consists of 16 weeks of training plus preceptorship and practicum.  I was impressed with the amount of telemedicine and telepharmacy that was in use at the clinic!

Alaska has a number of critical access hospitals that are located far from tertiary facilities.  The Alaska State Hospital and Nursing Home Association (ASHNHA) has formed a network of some of these smaller hospitals to "support the use of HIT as a tool to improve the quality and cost efficiency".  Like many other rural hospitals, these facilities struggle with finding HIT talent, and most of them have one IT person on staff with limited access to outside resources.  I spent a day with Jeannie Monk and spoke with the member CFOs about Meaningful Use and the financial incentives.  These hospitals are working closely with each other to find ways to share expertise and best practices, even though they are hundreds of miles apart in many cases.

Alaska is a vast, beautiful place.  The geography and size, along with a small population and cold winters, create significant challenges to providing health care to the native and non-native communities.  All three of the networks that I visited in June are doing amazing work to overcome these challenges.  There is much we can all learn from them.

Health Reform, the Supreme Court and Networks—Finding Comfort in the Chaos

Sally Trnka, Senior Program Coordinator

(This content was originally published in Cooperative Connections Newsletter)

Raise your hand if you are exhausted from the never ending news coverage, heated campaign promises, and scores of misinformation being broadcast pertaining to health care reform.  (It’s okay…go ahead!)  The complexities and confusion surrounding the recent Supreme Court decision aren’t lost on anyone and the confusion is compounded by election-year rhetoric and posturing that dismantles communication and banishes progress.  Since we’re not running for office, we’ll give it to you direct—and with a sprinkling of enthusiasm for the role of rural health networks in the changing healthcare landscape.  

The 5-4 Supreme Court ruling upholding the Affordable Care Act determined that the individual mandate, the most controversial part of the ACA, was a valid exercise in Congress’s power to tax (although it is not a valid exercise of the Commerce Clause, which was the clause that many opponents were expecting would deem the mandate unconstitutional).  In addition to upholding the policies and provisions that are scheduled to take effect in the coming years, the ruling solidified that the money, payment modifications and workforce modifications that have already gone into effect will not be rescinded. 

Okay, so that much you know, but what does all of this mean for rural?  There are a variety of rural-specific provisions within the ACA that will move forward as scheduled because of the ruling.  A compressive list of the rural-relevant provisions can be found on the website of the National Rural Health Association (NRHA).  Because it’s a long list, we’ll walk through a few of them, and why they are critical to the success of rural health care facilities. 

Approximately 25% of the country’s population resides in rural areas however, there are more rural Americans who are uninsured and underinsured than their urban counterparts.[1] The ACA contains provisions for the guaranteed issue and coverage renewability, along with the prohibition of exclusions based on pre-existing conditions.  This will help to ensure that more citizens are covered.  Increased coverage, however, does not equal access and workforce shortages will continue to be felt acutely in rural communities.  Currently, less than 10% of physicians serve the country’s rural population and with increased insurance coverage, the strain felt by providers will be even greater.  Included in the ACA are investments in the National Health Service Corps which will assist medical students with scholarships and loan repayment programs should they decide to practice in rural communities.  The ACA also designates critical access hospitals, for the first time, eligible sites for Corps assisted physicians.  The ACA also calls for increased funding for Area Health Education Center’s (AHEC) to improve the pipeline of potential future health care leaders, although the House of Representatives recently voted AHEC out of the running for funding for next year.  (Hopefully the Senate will reinstate funding.)  The improvement in the rural healthcare workforce will be vital to support the higher rates of chronic disease exhibited in rural communities[2].  With an increased focus on primary care and prevention, the ACA incentivizes patients to seek care before their condition becomes chronic or requires treatment from a specialist. 

Networks will play a crucial role in all of the health reform models as rural providers and hospitals become valuable players in both accountable care organization (ACO) and Medical Home demonstration projects.  The development and participation in ACO and the Medical Home concept all require collaboration, staff and resource sharing, collective innovation, and willingness to challenge the status quo.  Increasingly, rural hospitals will have to prepare themselves for a challenging future, based on value, quality transparency, and physician-hospital partnerships while maintaining a successful business model in the current system.  It’s is somewhat like navigating two canoes downstream with a leg in each canoe…it could end up being very painful!

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[1] Lenardson, J., Ziller, E., Coburn, A. & Anderson, N. Profile of Rural Health Insurance Coverage: A Chartbook. Rural Health Research and Policy Centers. June 2009. 

[2] Glasgow, N., Johnson, N., Morton, L. Critical Issues in Rural Health. Wiley-Blackwell. May 2004. 

A special thank you to the National Rural Health Association for their breakdown of the rural-relevant provisions in the ACA.